Low-Income Patients Say ER is Better Than Primary Care

July 9, 2013

One of the drivers of high health care costs in the United States is the use of emergency rooms (ER) for preventable conditions by patients who generally come from the most vulnerable populations. Estimated to cost as much as $30.8 billion a year in a recent Health Affairs study, avoidable ER use is a primary target for experts seeking to reduce health care costs.

To achieve this goal and “generate system-wide savings, experts need to listen to patients and address their concerns about the cost, quality and accessibility of outpatient care,” said Shreya Kangovi, MD, a Robert Wood Johnson (RWJF) Clinical Scholar (2010-2012) supported in part by the U.S. Department of Veterans Affairs.

Kangovi’s new study reports that current approaches to getting patients from low-socioeconomic groups to seek preventive and primary care in physicians’ offices or accountable care organizations instead of hospitals are often ineffective.

“Our findings suggest that these efforts could backfire by making hospitals even more attractive to these patients. We also debunk the notion that people from these groups abuse the emergency room for no reason and need to be taught how to use it properly.”

Insurance Status is Not the Key

Working from literature that shows ER usage patterns are not necessarily linked solely to insurance status, Kangovi explained that she “wanted to find a way to address the ongoing disparities” she saw in her patient population. “To do so, I designed the study so that we could talk with patients whose voices are seldom heard in policy discussions.”

Kangovi and her team conducted one-on-one interviews with 64 patients, ages 18-to-64, from two urban Pennsylvania hospitals. Forty of them met the criteria to be included in the study. They were uninsured or insured by Medicaid. The respondents, who were 90 percent African American, also lived in one of five Philadelphia zip codes where more than 30 percent of the residents had incomes below the poverty level.

“We asked them: ‘What are some of the reasons you might prefer to come to the emergency room rather than your primary care doctor’s office or clinic?’” Kangovi said. “The interviews were conducted by a community health worker who was a member of their community, so there was more of a trusting relationship.”

Study respondents (both the insured and uninsured) explained that they consciously chose the ER because the care was cheaper, the quality of care was seemingly better, transportation options were more readily accessible, and, in some cases, the hospital offered more respite than a physician’s office.

Excessive Barriers to Primary Care

“As a physician, I found the results very disturbing. We discovered that our system is just riddled with barriers to primary care,” Kangovi said. Patient voices taken from study interviews tell the story best:

Convenience. “You must call on the same day to set up a [primary] care appointment … whenever they can fit you in.” This open-access scheduling resulted in people taking days off from work and still being unable to see a doctor. It also made it impossible for many to access transportation covered by Medicaid because the transport arrangements had to made 72 hours in advance. Late hospital hours also made care more available.

Cost. “I don’t have a co-pay in the ER, but my primary [physician] may send me to two or three specialists and sometimes there is a co-pay for them. Plus there’s time off from work to go to several appointments.”

Quality. “The [primary care doctor] never treated me or my husband aggressively to get blood pressure under control. I went to the hospital and they had it under control in four days. The [physician] had three years.” This patient was one of many who expressed far more trust in the quality of hospital care.

Shelter from the Storm

In order to better understand study participants’ needs, Kangovi sorted them into two groups—those with five or more acute care episodes a month (group A) and those with less than five acute episodes a month (group B).

“The patients in group A had often gone through extraordinary trauma and were more likely to say that a traumatic event set off a cycle of social dysfunction, mental illness, and disability that drove their repeated hospital visits,” Kangovi explained.

“The group B patients were most often highly functional caregivers for social networks strained by poverty and illness. These people often put off caring for themselves. Both groups had extremely eloquent and valid reasons for avoiding preventive care, waiting to get sick and choosing emergency care,” she added.

Creating a National Model for Change

Acknowledging that this research has some limitations, such as the small size of the study sample, Kangovi intends to encourage other researchers to focus on vulnerable patients.

“I used the health services research training I gained as a Clinical Scholar, as well as the incredible support I received from my Clinical Scholar program mentors including my co-authors David Grande, MD, MPA, and Judith Long, MD, to address problems I saw from a public health and eventual policy perspective,” Kangovi said. “We plan to disseminate the study strategy.”

“We learned that the patients are the experts in the flaws in our health care system and the people we need to listen to,” Kangovi advised. “You hear the term ‘patient-centered care,’ well you have to talk to patients to create that care. Right now, they are telling us that we are creating a maze of hoops and hurdles that are driving them out of primary care and into the hospital.”